a nurse is interviewing a client who is requesting oral contraceptives which finding in the clients history is a contraindication to combined oral con
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment Form A

1. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?

Correct answer: C

Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.

2. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?

Correct answer: B

Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.

3. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

4. A client has been diagnosed with tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

Correct answer: B

Rationale: Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client with TB under airborne precautions to prevent the transmission of the disease. Choice A, contact precautions, are used for diseases that spread by direct or indirect contact. Choice C, droplet precautions, are for diseases transmitted by large droplets. Choice D, protective environment, is used for clients who have compromised immune systems.

5. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

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